northern ireland chronic kidney disease guidelines
TRANSCRIPT
1
Northern Ireland Guidelines for the Management
of Chronic Kidney Disease (CKD)
Practical Points for Use of Estimated GFR and
Albuminuria (ACR) in Assessing CKD
Developed by GAIN and the Northern Ireland Nephrology Forum
May 2015
2
Table of Contents Page
Introduction 3-4
Methodology 5-7
What is CKD and eGFR (estimated Glomerular Filtration Rate)? 8-9
What causes CKD? 10
Who should I screen for CKD? 10
What baseline investigations should I do in CKD? 10-11
How do I test for proteinuria? 11-12
What should I do if haematuria is present? 12-13
When should a kidney ultrasound be performed in persons with CKD? 13
Which CKD patients should I consider referring to the Renal Services? 14-15
What treatments are appropriate for CKD? 16-18
How should I monitor non-referred CKD? 18
What about a rise in serum creatinine or a fall in eGFR? 18-19
Urgency of referral to a nephrology service 19-20
Valuable information to include with a hospital referral 21
Patient involvement in CKD 21
Appendices
Appendix 1 - Where can I get more information? 22
Appendix 2 - Contact Details 23
Appendix 3 - Management of chronic kidney disease: summary table 24
Appendix 4 - Abbreviations 25
Appendix 5 - Membership of GDG 26
3
Introduction
Chronic kidney disease (CKD) is common, usually unrecognised and often exists in
association with other conditions such as diabetes and cardiovascular disease. CKD is a
general term covering a number of primary disease processes that result in structural
and/or functional kidney abnormalities persisting for at least three months.
CKD has emerged as a significant public health problem with up to 10% of adults having
evidence of underlying CKD or risk factors for CKD (Table 1). The majority of persons with
CKD have slow loss of kidney function and only a minority progress to end-stage renal
disease (ESRD) that requires renal replacement therapy (RRT). Moderate or severe CKD
is also associated with an increased risk of cardiovascular events, acute kidney injury,
falls, frailty and mortality.
Table 1: Prevalence of Chronic Kidney Disease
Stage Description eGFR
(mL/min/1.73m2)
Population
Prevalence
1 CKD with normal GFR
+ other kidney damage
>90 3.3%
2 Mild CKD and other kidney damage 60-89 3.0%
3a
3b
Mild to Moderate CKD
Moderate to Severe CKD
45-59
30-44
4.3%
4 Severe CKD 15-29 0.2%
5 Established renal failure <15 or on dialysis 0.2%
One challenging issue is that CKD is often not diagnosed because persons with kidney
disease usually have no specific symptoms. Late diagnosis of advanced CKD is
associated with increased morbidity and mortality. There is evidence that earlier treatment
may delay or prevent progression of CKD to end-stage renal disease (ESRD), reduce
complications and reduce the risk of cardiovascular disease.
4
CKD is no longer specifically incorporated in the General Practice Quality and Outcomes
Framework (QOF). However the five QOF indicators are hopefully embedded in practice
(generation of a register of patients with chronic kidney disease, measurement of blood
pressure, treatment of blood pressure to target, use (if appropriate) of ACEi or ARB
medication in patients with CKD and quantitative assessment of proteinuria). This 2015
guideline updates and replaces the 2010 GAIN Guideline for the Management of Chronic
Kidney Disease following the publication of the 2014 NICE Guideline on Chronic Kidney
Disease (CG 182).
The new and updated areas include reference to
Identification and investigation of people who have or are at risk of developing CKD
Classification of CKD
The definition of CKD progression
The relationship between Acute Kidney Injury (AKI) and CKD
Pharmacotherapy for CKD
5
Methodology
Who is the Guideline Intended For?
The guideline is relevant to all healthcare professionals who come into contact with
patients with chronic kidney disease.
It is also expected that this guideline will be of value to those involved in clinical
governance in both primary and secondary care to help ensure arrangements are in place
to deliver appropriate care to this group of patients.
The remit of the guideline is to develop a guideline for professionals caring for patients
with chronic kidney disease.
Terms of Reference for the Guideline
The Terms of Reference were developed by the Guideline Development Group (GDG) and
would be:
To write pragmatic clinical guidelines to help practitioners prevent, recognise,
investigate and manage chronic kidney disease
To integrate the clinical guideline into undergraduate and postgraduate clinical
teaching
Involvement of Stakeholders
Key to the development of GAIN guidelines is the involvement of relevant professional and
patient/carer organisations. A list of the GDG for Northern Ireland Guidelines for the
Management of Chronic Kidney Disease (CKD) can be found in Appendix 5.
Needs Assessment
As part of the guideline development process, a meeting was held with the key
stakeholders to identify pragmatic questions related to the prevention, recognition,
6
investigation and management of CKD. The stakeholders also considered how the
guideline information could be incorporated into undergraduate and postgraduate clinical
education in an effort to disseminate best practice.
The literature review for this guideline retrieved articles and guidelines published within the
previous 10 years (2003-13). This was obtained by searching databases including
Medline, Embase, Cinahl, PsycINFO and The Cochrane Library (Wiley). The main
searches were supplemented by material identified by individual members of the
development group. Searches were limited to retrieve material published in English. A list
of references can be found at http://www.gain-ni.org/index.php/audits/evidencetables.
Who Developed the Guideline?
Overview
Based upon methods outlined in the āAdvice for Guideline Development in Northern
Irelandā document a team of health professionals, lay representatives, technical experts
and GAIN known as the GDG (see Appendix 5), undertook the development of this clinical
guideline. The basic steps in the process of developing a guideline were also taken from
Appendix 5 of the āAdvice for Guideline Development in Northern Irelandā document.
The Guideline Development Group (GDG)
The Northern Ireland Guidelines for the Management of Chronic Kidney Disease (CKD)
GDG were recruited by requests for nominations being sent to the main stakeholder
organisations and patient organisations/charities.
At the start of the guideline development process all GDG membersā interests were
recorded on a standard declaration form that covered consultancies, fee-paid work, share-
holdings, fellowships and support from the healthcare industry. At all subsequent GDG
meetings, members declared new, arising conflicts of interest which were recorded.
7
Guideline Development Group Meetings
Six meetings were held between July 2014 and March 2015. During each meeting clinical
questions and clinical and economic evidence were reviewed and assessed and
recommendations formulated. At each meeting patient/carer and service-user concerns
were routinely discussed as part of a standing agenda item.
The Chair divided the GDG workload by allocating specific topics, relevant to their area of
clinical practice to small sub-groups of the GDG in order to simplify and speed up the
guideline development process. These groups considered the evidence, as reviewed by
the systematic reviewer, and synthesised it into draft recommendations prior to presenting
it to the GDG as a whole.
Patient/carer Representatives
A user representative participated on the GDG providing valuable perspective on patient
experience of CKD. The user representative reflected the views of persons living with
chronic kidney disease in Northern Ireland.
Expert Advisers
During the development phase of the guideline the GDG identified areas where there was
a requirement for expert input on particular specialist topic areas. The topics were
addressed by either the production of a position paper or a formal presentation by a
recognised expert who had been identified via the relevant registered stakeholder
organisation. All relevant position papers are presented as part of the evidence review.
Updating the Guideline
In keeping with GAIN requirements these guidelines will be reviewed in 2018 or sooner in
light of any emerging evidence.
Funding
The GDG was commissioned by GAIN to develop this guideline. The GDG did not receive
any payment or remuneration in kind for their work developing the guideline.
8
What is CKD and eGFR (estimated Glomerular Filtration Rate)?
CKD can manifest as either reduced kidney function (reduced GFR) or urinary
abnormalities (haematuria/proteinuria) or a combination of both present for more than 3
months.
CKD is classified according to estimated GFR (eGFR) and the urinary
albumin:creatinine ratio (ACR) (Table 2 and Table 3). G denotes the GFR categories
(G1-5) which have the same GFR thresholds as the CKD stages 1 ā 5.
The ACR category is denoted as A (for albuminuria) with three categories: A1, A2 or
A3. The ACR category has been introduced to emphasise that patients with higher
levels of proteinuria (in any eGFR stage) have an increased risk of progression to
ESRD and other adverse outcomes.
o A1 is an ACR of < 3mg/mmol (normal)
o A2 is an ACR in the range 3 ā 30mg/mmol (micro-albuminuria)
o A3 is an ACR > 30mg/mmol (macro-albuminuria often dipstick proteinuria)
GFR in healthy young adults is approximately 100 mL/min/1.73m2. An eGFR result can
be explained to patients as an approximate percentage of normal kidney function.
eGFR is an estimate of renal function (GFR) based on serum creatinine but also
accounting for differences in gender, ethnicity and age which affect muscle mass and
thus serum creatinine generation. Laboratories report it whenever any serum creatinine
in patients aged 18 years or above is requested.
If the eGFR is 60 mL/min/1.73m2 or greater, the diagnosis of CKD requires the
presence of other kidney damage e.g. persistent proteinuria (albumin-creatinine ratio
>30 mg/mmol), persistent non-visible (microscopic) haematuria or structural kidney
disease e.g. polycystic kidney disease.
In Northern Ireland, laboratories do not routinely report eGFR >60mL/min/1.73m2.
Thus, CKD stages 1 and 2 would require urinalysis or renal imaging to allow CKD
definition.
9
Table 2: Categories of Chronic Kidney Disease Based on Glomerular Filtration Rate
GFR category GFR (mL/min/1.73m2)
G1 >90
G2 60-89
G3a 45-59
G3B 30-44
G4 15-29
G5 <15
Table 3: Categories of Chronic Kidney Disease Based on Albuminuria
ACR category ACR (mg/mmol)
A1 <3
A2 3-30
A3 >30
10
What Causes CKD?
Specific causes include conditions such as diabetes, atheromatous renal vascular
disease, glomerulonephritis, pyelonephritis and polycystic kidney disease.
For many persons, no specific cause is identified and the CKD is presumed to be
related to hypertensive or ischaemic kidney damage (both of which become more
common with advancing age).
Who Should I Screen for CKD?
Offer testing for CKD using eGFR and ACR to people with the following risk factors:
Diabetes
Hypertension
Cardiovascular disease (ischaemic heart disease, heart failure, peripheral
vascular disease or cerebral vascular disease)
Structural renal tract disease, recurrent renal calculi or prostatic hypertrophy
Multisystem diseases that may impact on kidney function (i.e. SLE,
rheumatoid arthritis, sarcoidosis)
Family history of end-stage renal disease or hereditary kidney disease
Monitor people for the development of CKD for two years after AKI,
especially if the serum creatinine has not returned to baseline.
Opportunistic detection of haematuria
Monitor GFR at least annually in people prescribed drugs known to be nephrotoxic (for
example, ciclosporin or tacrolimus, lithium and NSAIDs)
What Baseline Investigations Should I Do in CKD?
In patients with newly identified reduced eGFR (i.e. <60 mL/min/1.73m2), the first step
is to exclude acute kidney injury. Review of previous serum creatinine tests may allow
confirmation that this is chronic kidney disease. Otherwise the patient should have a
repeat serum creatinine (eGFR) within one week if normal electrolytes or within 48
hours if abnormal electrolytes (e.g. hyperkalaemia).
11
If possible, patients should be advised not to eat any red meat 12 hrs before their blood
test as the serum creatinine may be artificially elevated resulting in an erroneously
lower eGFR. In practice a morning blood sample avoids this issue rapidly declining
kidney function (over days to weeks) is acute kidney injury and urgent referral for
assessment is advised.
In all newly identified CKD patients the following should be checked at the earliest
opportunity:
electrolytes
blood pressure
dipstick urinalysis
random urine albumin-creatinine ratio or urine protein-creatinine ratio
glucose, cholesterol and full blood count.
How Do I Test for Proteinuria/Albuminuria?
Reagent strips for dipstick urinalysis provide a simple screening test but are not an
accurate method of quantifying proteinuria. Reagent strips cannot detect low
concentrations of albumin in the urine.
Use a random urine albumin-creatinine ratio (ACR) to detect albuminuria in persons
with diabetes and individuals without diabetes who have an eGFR < 60 mL/min/1.73m2
The urine ACR result may be normal (< 3 mg/mmol).
If the ACR is between 3 mg/mmol and 70 mg/mmol, this should be confirmed by a
subsequent early morning sample. This is because patients may exhibit transient
microalbuminuria without any clinical significance. However if the initial ACR is 70
mg/mmol or more a repeat confirmatory sample is not needed
Use urine ACR in preference to protein:creatinine ratio (PCR) as ACR has greater
sensitivity for low levels of proteinuriaFor quantification and monitoring of high levels of
proteinuria (ACR >70 mg/mmol) PCR can be used as an alternative.
Progression of CKD (decline in eGFR) and cardiovascular events are more common if
albuminuria (or proteinuria) is present.
12
Approximate Equivalent Values of ACR, PCR and Urinary Protein Excretion
ACR (mg/mmol) PCR (mg/mmol) Urinary Protein Excretion (g/24h)
30 50 0.5
70 100 1
What should I do if haematuria is present?
Asymptomatic non-visible haematuria is a very common in general practice with a
prevalence of 2 - 13% in screened individuals.
There is currently no evidence to justify screening of the general population.
Excellent short clinical guidelines on assessment of haematuria were published by the
British Association of Urological Surgeons and Renal Association and should be read in
association with the summary in this GAIN document (see Appendix). In addition, a recent
BMJ Practice Review provides concise guidance of assessment of asymptomatic non-
visible haematuria (see Appendix)
The causes of haematuria vary with clinical presentation and age and in many such
patients, particularly young adults, haematuria is transient and may be of no consequence.
The most common causes are urological such as kidney or urinary tract malignancy,
stones, inflammation, infection or hyperplasia of the prostate or bladder. Only 10% of
patients with haematuria will have a renal parenchymal cause. In up to 60% no diagnosis
will be found despite complete assessment.
The following steps should be taken in the assessment of patients with haematuria:
1. Urinary tract infection - should be excluded by absence of nitrite and leucocyte on
dipstick and negative MSU. Urinalysis should be repeated following treatment of a
UTI to ensure haematuria is not persistent.
2. History/Examination ā are there any findings that suggest a particular diagnosis?
3. Investigations - serum creatinine / eGFR, urinary ACR, bone profile, CRP,
haemoglobin
13
4. Referral criteria - Referral for urological evaluation including renal imaging and
cystoscopy is required in all patients with significant haematuria as defined by:
a) Any single episode of Visible Haematuria, otherwise known as macroscopic or
gross haematuria, at any age.
b) Non-Visible Haematuria, otherwise referred to as microscopic or dipstick
positive haematuria, is significant if a single episode is symptomatic at any age
(hesitancy, frequency, urgency, dysuria) or if it is persistent (defined as two out
of three dipsticks positive) and aged over 40.
If a urological cause is excluded a nephrology referral should be considered if the patient
meets any of the CKD criteria for referral or has:
Significant proteinuria (ACR ā„30mg/mmol or PCR ā„50mg/mmol =0.5g/24hr)
Evidence of progressive CKD
o a sustained decrease in eGFR of 25% or more and a change in GFR
category within 12 months or
o a sustained decrease in eGFR of 15mL/min/1.73m2 per year
Stage 4 or 5 CKD (eGFR <30mL/min/1.73m2)
Isolated haematuria (i.e. in the absence of significant proteinuria) with hypertension
in those aged <40.
Visible haematuria coinciding with intercurrent (usually upper respiratory tract)
infection
In the event the above criteria are not met, haematuria itself (visible or non-visible) does
not require nephrology referral.
When Should a Kidney Ultrasound be Performed in Persons with CKD?
A kidney ultrasound is recommended for persons with CKD who:
have progressive CKD
have visible or non-visible haematuria
have symptoms of urinary tract obstruction
have a family history of polycystic kidney disease and are aged over 20 years
have stage 4 or 5 CKD
14
Which CKD Patients Should I Consider Referring to the Renal Service?
1. General points
Take into account the individualās wishes and co-morbidities when considering
referral to a specialist.
Some individuals with advanced CKD (and their families) would not wish to consider
renal replacement therapy e.g. dialysis and therefore referral may not be
appropriate
Consider discussing management issues with a specialist (virtual referral) where it
may not be necessary for a patient to attend for hospital-based assessment
Patients who seem too frail for dialysis may still be discussed as there are some
non-dialytic management options. The risk of AKI can still be reduced in these
frailer patients by avoiding nephrotoxic drugs and early treatment of inter-current
illness.
2. Based on eGFR
Patients with new CKD 5 (eGFR <15 mL/min/1.73m2) should be discussed
immediately
Patients with new CKD 4 (eGFR 15-29 mL/min/1.73m2) - refer or discuss
Patients with progression of CKD confirmed on repeat testing
o a sustained decrease in eGFR of 25% or more and a change in eGFR
category within 12 months or
o a sustained decrease in GFR of 15mL/min/1.73m2 per year - refer routinely
3. Based on Proteinuria
Patients with an ACR or PCR >300 mg/mmol and/or the nephrotic syndrome
should be referred urgently
Patients with an ACR or PCR 100-300 mg/mmol - refer routinely
Patients with an ACR or PCR 30-100 mg/mmol AND haematuria ā refer routinely
15
Clinical judgement may suggest other patients who should be referred, or a different
degree of urgency.
4. Based on Blood Pressure
Patients with eGFR <60 mL/min/1.73m2 + inadequately controlled blood
pressure despite 2-3 antihypertensive agents should be referred routinely
Suspected renal artery stenosis
5. Known or suspected rare or genetic causes of CKD
16
Treatment
What Treatments are Appropriate for CKD?
General Points
Review existing medication. Avoid chronic NSAIDs use; extreme care with short
term use. Adjust other medication dose(s) according to eGFR using Appendix 3 in
BNF.
Advise lifestyle changes as appropriate: smoking cessation, reduction of obesity,
increased exercise and reduce dietary salt intake to < 6 grams/day.
Hypertension
Treat blood pressure ideally to <140/90 mmHg. Multiple agents may be required and
the threshold for starting treatment is 140/90 mmHg
If urine albumin-creatinine ratio ā„70 mg/mmol treat blood pressure ideally to <130/80
mmHg. ACEi/ARBs are first choice therapy.
Offer an ACEi or ARB to people with CKD and
o Diabetes and an ACR of 3 mg/mmol or more
o Hypertension and an ACR of 30 mg/mmol or more
o An ACR of 70 mg/mmol or more
o Do not use a combination of ACEi and ARB
Serum creatinine/eGFR should be checked 7-10 days after starting, or increasing the
dose of an ACEi or ARB. These drugs may cause a rise in serum creatinine or fall in
eGFR. If serum creatinine increase is >25% or eGFR decrease is < 25% from baseline,
repeat the test in one to two weeks. If no further change then the current dose can be
tolerated.
Stop ACEi or ARBs if the serum potassium increases to 6 mmol/L or more. In such
cases, instigation of a low potassium diet and cessation of other drugs which promote
hyperkalaemia may allow reintroduction of ACEi or ARBs.
17
Statins
Do not use a risk assessment tool to assess cardiovascular disease (CVD) risk in
people with a GFR < 60 mL/min/1.73m2 as these persons are at increased risk of
CVD.
Offer atorvastatin 20mg for the primary or secondary prevention of CVD especially
to people aged over 40 with CKD.
Increase the dose if a greater than 40% reduction in non-HDL cholesterol is not
met.
Oral Antiplatelets and Anticoagulants
Consider anti-platelet agents for the secondary prevention of cardiovascular disease
Consider apixabab in preference to warfarin in people with an eGFR in the range 20 ā
50 mL/min/1.73m2 and non-valvular atrial fibrillation who have one or more of the
following risk factors; prior stroke or transient ischaemic attack, age 75 or older,
hypertension, diabetes mellitus, symptomatic heart failure.
Bone Metabolism and Osteoporosis
Offer bisphosphonates if indicated for the prevention and treatment of osteoporosis
in people with an eGFR >30 mL/min/1.73m2
Offer colecalciferol to people with CKD who have been identified to have vitamin D
deficiency
A Note of Caution: Decline in GFR with age is incompletely understood at present and
there is a need to refine and validate the eGFR equation especially when considering
elderly patients (> 70 yr) with low eGFR.
The CKD classification system will identify many elderly subjects with low eGFR who do
not have "true" kidney disease (as defined by steadily progressive kidney failure in
association with other abnormal features such as proteinuria). Most CKD in the elderly is
due to the cumulative effect of other disease states, especially hypertension and
18
atherosclerosis. It is important not to unduly alarm elderly patients with a misplaced
diagnosis of advanced kidney failure.
How Should I Monitor Non-Referred CKD?
A majority of patients with CKD do not need to be referred and are well managed in
primary care. A CKD register should be established for CKD stages 3, 4 and 5 to allow re-
call arrangements. This would include patients with mild proteinuria (ACR 30-70 mg/mmol,
isolated non-visible haematuria (after assessment by urology if appropriate see RA/BAUS
guidelines 2008) and stable CKD 3 or 4. Suggested monitoring for these patients
depending on their eGFR stage and ACR level and some of the associated targets is
summarised in Table 4.
The frequency of eGFR monitoring should be tailored to changes to their treatments (such
as change in dose of ACEi/ARBs, diuretics, NSAIDs), intercurrent illness and whether they
have chosen conservative management of their CKD.
What About a Rise in Serum Creatinine or a Fall in Egfr?
Large rises in serum creatinine (>30%) and the corresponding falls in eGFR are
associated with inter-current acute illness particularly in the frail elderly population.
There is often underlying vascular disease; diabetes and heart failure with the
associated treatments. A falling eGFR will require closer monitoring.
A sustained fall in eGFR (reduction of >15 mL/min/1.73m2) should be confirmed by
repeating serum creatinine/eGFR within one month.
Progressive CKD is usually defined by at least three eGFRs over at least 90 days
Many CKD patients exhibit minor fluctuations in their serum creatinine/eGFR (often
linked to diuretic / ACEi therapy or inter-current illness).
Temporary cessation of ACEi or ARBs can often correct these changes if the patient is
at risk of dehydration.
Chronic use of NSAIDs may be associated with progressive CKD; use with caution and
ideally for only for short term.
Drugs which contain trimethoprim can also result in a marked increase in serum
creatinine without directly affecting kidney function. The serum creatinine should be
repeated to obtain a more accurate serum creatinine (and eGFR) 48hrs after
trimethoprim containing medications are stopped.
19
Patients with CKD should be referred if they have a SUSTAINED decrease in eGFR of
15mL/min/1.73m2 per year.
Urgency of Referral to a Nephrology Service
All nephrology services should offer 24 hour telephone access to qualified advice. A guide
to referral urgency is below:
Immediate
Suspected AKI
AKI superimposed on CKD
Newly detected stage 5 CKD (eGFR < 15 mL/min/1.73 m2)
Accelerated or malignant phase hypertension with suspicion of underlying
kidney disease (or if there is no specialist hypertension service available
locally)
Hyperkalaemia, serum potassium ā„ 7.0 mmol/L
Urgent Outpatient
Nephrotic syndrome
Newly detected stage 4 CKD (unless known to be stable) or stable stage
5 CKD
Multisystem disease (e.g. SLE, systemic vasculitis) with evidence of
kidney disease
Hyperkalaemia, serum potassium 6.0- 6.9 mmol/L (after exclusion of
artefactual and treatable causes
Routine Outpatient
Refractory hypertension (defined as sustained BP >160/90 mm Hg despite
combination therapy with three drugs from complementary classes).
Acute deterioration in kidney function (defined as a fall in eGFR of >25% or
rise of serum creatinine concentration of >30% from baseline) associated
with use of ACEi or ARBs
Proteinuria (urine protein:creatinine ratio >70 mg/mmol) without nephrotic
syndrome.
Proteinuria with haematuria
Stage 3 CKD with haematuria
20
Urologically unexplained visible (macroscopic) haematuria (with or without
proteinuria).
Stable stage 4 CKD
GP care +/- āvirtualā nephrology support/advice
Stable CKD stages 1, 2 and 3
Isolated non-visible (microscopic) haematuria (after negative urological
evaluation)
Isolated microalbuminuria in diabetes (albumin: creatinine ratio <
30mg/mmol)
21
Valuable Information to Include With a Hospital Referral
General medical history - particularly noting urinary symptoms, previous blood
pressures, urine testing.
Information on the patientās functional status and cognitive function is especially
relevant if dialysis is being considered as a treatment option.
Medication history.
Examination e.g. blood pressure, presence of oedema, vascular disease findings.
Urine dipstick result - and quantitation of dipstick positive proteinuria by urine
albumin/creatinine ratio or protein/creatinine ratio.
Blood tests - Full blood count, urea and electrolytes, calcium, albumin, phosphate,
cholesterol. HbA1c (in diabetes).
Previous tests of renal function with dates.
Imaging: - results of renal imaging if undertaken (according to local circumstances, pre-
ordering may speed assessment).
Patient Involvement in CKD
If CKD is identified offer people education and information tailored to:
establishing the cause of CKD
severity of CKD and risk of progression
monitoring
treatments and need for Nephrology referral
Support self-management:
blood pressure, smoking cessation, exercise, diet and medicines
access to their medical data to encourage self-management of their CKD
22
Appendix 1
Where Can I Get More Information?
https://www.nice.org.uk/guidance/cg182
Chronic kidney disease: early identification and management of chronic kidney disease
in adults in primary and secondary care National Institute for Health and Clinical
Excellence (2014)
www.renal.org/eGFR
Renal Association website quick access to info about eGFR and CKD stages with links
to management.
http://renux.demed.ed.ac.uk/EdREN/index.html
Website of the Edinburgh Renal Unit with may helpful articles on kidney disease that
are suitable for both health care professionals and patients.
http://www.renal.org/pages/media/Guidelines/RA-
BAUS%20Haematuria%20consensus%20guidelines%20July%202008.pdf
British Association of Urological Surgeons / Renal Association: Initial assessment of
haematuria.
Investigating asymptomatic invisible haematuria. BMJ Practice Review. BMJ 2014;
349:g6768
Access to these guidelines and any future updates
http://www.gain-ni.org/
Guidelines and Audit Implementation Network (Northern Ireland)
The GAIN website also displays other topic guidelines with relevance to the management
of chronic kidney disease. These include
Acute Kidney Injury Guidelines (GAIN 2014)
Hyperkalaemia guidelines (GAIN 2014)
23
Appendix 2
For further advice on Chronic Kidney Disease contact your local Nephrologist
Name Telephone Email
Altnagelvin and Tyrone County Hospitals
Dr S Bolton (028) 7134 5171 [email protected]
Dr M Elawad (028) 7134 5171 [email protected]
Dr Y Kuan (028) 7134 5171 [email protected]
Dr F McCarroll (028) 7134 5171 [email protected]
Dr G Shivashankar (028) 7134 5171 [email protected]
Dr S Prabhavalkar (028) 7134 5171 [email protected]
Antrim Area Hospital
Dr R Cunningham (028) 9442 4889 [email protected]
Dr JC Harron (028) 9442 4889 [email protected]
Dr RN Mullan (028) 9442 4889 [email protected]
Dr MP Quinn (028) 9442 4889 [email protected]
Belfast City Hospital
Dr E Borthwick (028) 9504 9404 [email protected]
Dr JH Brown (028) 9504 9404 [email protected]
Dr AE Courtney (028) 9504 9404 [email protected]
Dr DG Fogarty (028) 9504 9404 [email protected]
Dr J Hanko (028) 9504 9404 [email protected]
Dr C Hill (028) 9504 9404 [email protected]
Prof AP Maxwell (028) 9504 9404 [email protected]
Dr J Shields (028) 9504 9404 [email protected]
Dr JD Woods (028) 9504 9404 [email protected]
Daisy Hill Hospital
Dr JC Harty (028) 3083 5077 [email protected]
Dr PJ McKeveney (028) 3083 5077 [email protected]
Dr NA Morgan (028) 3083 5077 [email protected]
Ulster Hospital, Dundonald
Dr N Leonard (028) 9056 4838 [email protected]
Dr JS Smyth (028) 9056 4838 [email protected]
Dr AM Woodman (028) 9056 4838 [email protected]
24
Appendix 3
Table 4: Suggested Monitoring of Chronic Kidney Disease in General Practice
STAGE G1 G2 G3a G3b G4 G5
U&E and ACR
(per year)
A1-3: once A1-2:
once
A1-2:
once
A3:
twice
A1-2: twice
A3: three
times
ā„4 times
Treatment
Treat BP to a target of < 140/90 mmHg
(130/80 if urine ACR ā„ 70 mmol/mol)
ACEi or ARB ONLY if
-ACR ā„ 3 mg/mmol & diabetes
-ACR ā„ 30 mg/mmol &BP ā„ 140/90
-ACR ā„ 70 mg/mmol
Consider a statin + aspirin 75mg for secondary prevention
Advise lifestyle changes as appropriate
Referral
Progressive CKD
Decrease GFR of ā„ 15mL/min/1.73m2 over
12 months Ā± urine ACR ā„ 70 mg/mmol
Ā± systolic BP ā„ 160 mmHg (despite
treatment with multiple agents)
Discussion
with or
referral to
renal unit is
usual
Usually
automatic
(unless not
for active
treatment
based on
comorbidity)
25
Appendix 4
Abbreviations
ACEi angiotensin converting enzyme inhibitor
ACR urine albumin/creatinine ratio
AKI acute kidney injury
ARB angiotensin-II receptor blocker
CKD chronic kidney disease
CVD cardiovascular disease
eGFR estimated glomerular filtration rate
ESRD end-stage renal disease
NSAIDs non-steroidal anti-inflammatory drugs
PCR urine protein/creatinine ratio
26
Appendix 5
Membership of GAIN CKD Guideline Development Group
The Northern Ireland Guidelines for the Management of Chronic Kidney Disease (CKD):
Practical Points for use of estimated GFR and albuminuria (ACR) in assessing CKD were
developed by:
Chairman
Prof Peter Maxwell Consultant Nephrologist Belfast HSC Trust
Co-Chair
Dr John Harty Consultant Nephrologist Southern HSC Trust
GDG Group
Dr Emma Borthwick Consultant Nephrologist Belfast HSC Trust
Dr Paul Conn General Practitioner Belfast
Dr Neal Morgan Consultant Nephrologist Southern HSC Trust
Nicola Porter Manager GAIN
Dr Patrick Sharkey General Practitioner Carryduff
Dr Colin Thompson Chairman NI Kidney Patients Association
The GDG were also supported by the members of the Northern Ireland Regional
Nephrology Forum.
27
Contact Details
GAIN
Regulation and Quality Improvement Authority
9th Floor, Riverside Tower
5 Lanyon Place
BELFAST
BT1 3BT
Tel: (028) 9051 7500
Fax: (028) 9051 7501
Email: [email protected]
Web: www.GAIN-ni.org
www.rqia.org.uk
Assurance, Challenge and Improvement in Health and Social Care
ISBN Number: 978-1-906805-34-0